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Hawaii vets have experienced some of the longest waiting times in the nation before they can get in to see a primary care doctor — although veterans officials have recently said that initial wait time has come down considerably.

Hawai’s track record was so bad that U.S. Rep. Tulsi Gabbard has of director Wayne Pfeffer, alleging incompetence and misinformation stemming from his office.

But VA officials have blamed a burgeoning patient load, and said so at a mid-August congressional field hearing in Honolulu chaired by U.S. Sen. Mazie Hirono at the Oahu Veterans Center.

In addition to submitted by high-level VA officials, Pfeffer, the Hawaii director said: “We’ve grown 20 percent over the past three years which is one of the largest growths in the VA system so we have a large number of people coming to our system.”

Has the VA caseload grown significantly in Hawaii?

First, we asked Pfeffer’s office what, exactly, he meant. Grown how?

We spoke to Pfeffer’s executive assistant, Craig Oswald, to clarify.  He says the VA officials presented a simplified number at the hearing to avoid possible confusion over terminology.

What Pfeffer meant, he says, was a 20 percent increase in workload over the last three years.  To trace that number, we’ll have to take a look at both “unique patients” and “encounters.”

The first data set we looked at was that of “unique patients.” According to , a patient is “counted as a unique in each division from which they receive care.  For example, if a patient receives primary care at one VA facility and specialty care from another, he/she will be counted as a unique patient in each division.”

The VA keeps track of patients by their Social Security numbers. Every time a new SSN is plugged in at a doctor’s office, the number of unique patients ticks up one. Should the same person visit a psychologist, then an endocrinologist, and then break an arm, that would count as three unique patients, (and one unlucky hypothetical person.) Follow-up visits with any of those doctors, however, wouldn’t count until the next year.

According to J. Scott Hallmark, administrative officer to the chief of staff at VAPIHCS, “We count uniques because it gives us a sense of how many individuals in a given time period (a year for our discussion) that actually seek services from us.”

Note: The VA measures data in fiscal years, which for the federal government begin Oct.1 and end Sept. 30 of the next year.  Hence, FY11 would mean Oct. 1, 2010, to Sept. 30, 2011.  All data is given in fiscal years unless otherwise noted.

Here’s the numbers the VA gave us for unique patients:

FY11:  26,426
FY12:  28,345
FY13:  30,993
FY14:  34,500  (projected)

That  works out to be yearly increases of 7 percent, 9 percent,  and 11.3 percent between each year. But it’s a 17 percent growth in unique patients from 2011 to 2013.  If we take into account the projected 2014 numbers, it’s a 30 percent increase over three years.

But those numbers for unique patients treated fail to take into account repeat visits, which is important when we’re considering whether the VA in Hawaii has just grown so big that long wait times are a consequence. Should, say, a diabetic need multiple trips to an endocrinologist, that patient would only count as one unique patient, even though the doctor would be working more hours.

This is where the term “encounters” comes in.  The VA uses it to mean total outpatient visits each year.

Those numbers are:

FY11: 268,805
FY12: 291,681
FY13: 315,089
FY14: 337,000  (projected)

(Through the end of August, FY14 saw 308,970 encounters. That makes an average of 28,088 visits a month. The projected number is, by that metric, accurate.)

A look at the percentage difference shows an 8.5 percent, 8 percent, and 7 percent increase in encounters each year.

From FY11 to FY13, that’s a 17 percent increase — 25 percent if we include projected numbers for FY14.

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By these numbers, it’s safe to say Wayne Pfeffer is largely correct in his assessment that the VA Pacific Islands Health Care System has grown by double digits over three years. In the two-year span before he took his position in October 2013, the agency had already grown 17 percent in both unique patients and encounters. But, should we count projected numbers for the current fiscal year, (which we should, it’s almost over)  those numbers jump to a 30 percent increase in patients against a 25 percent increase in doctor’s visits.

We could’ve stopped there, but that wouldn’t tell the whole story. VAPIHCS officials portray the agency as one that’s strained, and doing the best it can. Those numbers tell us that, yes, demand for VA health services has grown in Hawaii and the Pacific islands. But they don’t give us a sense of  how equipped the agency is to do it’s job. 

So we looked at budget and staff.

First, yearly budgets were:

FY11: $222,306,266
FY12: $222,178,888
FY13: $238,735,121
FY14: $251,000,000 (projected)

Across the years, that makes a 0.05 percent decrease, a 7.5 percent increase, then a projected 5 percent increase.

Total, that’s a 12.9 increase increase from FY11 to FY14.

Then we looked at staff.

Numbers we’ve obtained came in the form of FTEE. For those who aren’t accountants, that means “full-time-equivalent employees.” It’s a term the IRS uses to determine how many people, on average, are doing full-time work. Basically, divide total hours worked, by everyone, in a week by 40, and that counts as one person.

FY11: 777
FY12: 799
FY13: 866
FY14: 925  (projected)

Yearly differences were 2.8 percent,  8 percent,  and 6.8 percent. That marks 19 percent increase in staff from FY11 to FY14.

Let’s recap. From 2011, VA Pacific Islands Health Care Services has seen a 30 percent in unique patients, and a 25 percent increase in doctor’s visits but has only seen a 12.9 percent increase in funding and a 19 percent increase in staff.

So, is Wayne Pfeffer’s statement that VAPIHCS has “grown 20 percent over the last three years” true? Mostly, yes, because we’re being generous. But it’s a few percentage points off, and his statement was vague and over-simplified.

More importantly, given that the VA Pacific Islands Health Care System has also seen an increase in workload significantly higher than its increase in resources, we also agree that system growth is very likely a contributing factor to the long wait times, as his testimony suggested.